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09.09.05 Issue #183
   
A FEE! WHAT FEE ARE YOU TALKING ABOUT?

Tom Limoli, Jr.

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Both the legal profession and the dental community seem to have an infatuation regarding fees and fee schedules. So as to shed light upon this very gray and confusing subject, let’s address several standard definitions that you may or may not have in your working vocabulary.

Your office has only one FEE SCHEDULE that lists the USUAL FEE for each procedure that you perform. State dental boards and other regulatory authorities frown on doctors that have multiple FEE SCHEDULES. (i.e.: one for insured and one for non‑insured patients).

The USUAL FEE is that fee which appears in your office FEE SCHEDULE. The USUAL FEE is that amount of money which you charge in the open, free market, economy. It represents your full fee and has nothing to do with that amount of money contractually reimbursed by the patient’s benefit plan. This is simply the doctor’s baseline standard.

Benefit plan administrators statistically establish CUSTOMARY FEE levels. These levels are established based upon the dollar amounts and frequencies that are submitted on claims to the benefit plan or administrative entity. One hundred claims for $30 each has more weight than ten claims for $40 each. The more times the event occurs the more CUSTOMARY it becomes. Fee data are most often grouped into frequency percentiles.

In an insurance free fee-for-service environment doctors charge whatever they feel is appropriate. When a dental office modifies its USUAL FEE it is most often identified as simply being a REASONABLE FEE. Fees are and can be modified for any number of reasons. Charge more for a prophy due to patients’ previous neglect? Charge less for a pediatric extraction?

It is not an unreasonable action when a benefit plan contractually does not honor the doctor’s modified USUAL FEE. On the same note it is not unreasonable to deny a child chocolate ice cream for breakfast.

Your office may participate with various benefit plans and have several different TABLE OF ALLOWANCES. These are based on contractually agreed upon dental plans of which the practitioner is identified as a preferred or designated provider. The amounts identified on a TABLE OF ALLOWANCE are not to be confused with fees. The dollar amounts identified in a TABLE OF ALLOWANCE are nothing more than a representation of the total dollar obligation on the part of the plan. It has nothing to do with your usual fee or what you charge.

Both participatory and non-participatory benefit plans reimburse for specific services based on a MAXIMUM ALLOWANCE. These plans generally reimburse up to 100% of a predefined dollar amount. The dollar amount of reimbursement is based upon the financial strength of the plan as defined by the contract with the purchaser – not insurance company. The difference between that predefined level of reimbursement and your USUAL FEE is to be paid by the patient in a true fee-for-service environment.

Plan reimbursement based upon MAXIMUM ALLOWANCES should not be confused with the surcharges paid by the patient under a MAXIMUM FEE SCHEDULE plan. Surcharges apply only to those patients that are participating in specific, most often prepaid, benefit plans. The differences between MAXIMUM FEE SCHEDULE and MAXIMUM ALLOWANCE plans are, primarily, the levels of financial participation on the part of the patient. With both plans, your USUAL FEE is not taken into consideration by the plan. With MAXIMUM ALLOWANCES the patient is responsible to your office for your full USUAL FEE. Participating dentists cannot collect their full USUAL FEE from patients covered by MAXIMUM FEE SCHEDULE plans.

Remember the words of the great dental philosophers from Chicago: "the patient is responsible for the total cost of dental care".

COST! WHAT COST ARE YOU TALKING ABOUT?

USUAL FEE
The fee that an individual dentist most frequently charges for a given dental service.

FEE SCHEDULE
A list of the charges established or agreed to by a dentist for a specific dental service.

REASONABLE FEE
The fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complication or unusual circumstances, and therefore may differ from the dentists "usual" fee or the benefit administrator's "customary' fee.

CUSTOMARY FEE
The fee level determined by the administrator of a dental benefits plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that procedure.

TABLE OF ALLOWANCES
A list of covered services with an assigned dollar amount that represents the total obligation of the plan with respect to payment for such services, but does not necessarily represent the dentist's full fee for that service.

MAXIMUM ALLOWANCE
The maximum dollar amount a dental program will pay toward the cost of a dental service as specified in the program's provision.

MAXIMUM FEE SCHEDULE
A compensation arrangement in which a participating dentist agrees to accept a prescribed sum as the total fee for one or more covered services.

If you are interested in having a comparative Fee Schedule Review - 7 page report detailing 216 of the most often performed dental procedures compared to your existing fee schedule complied for your zip code, please email info@mckenziemgmt.com.

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